In todays health care system, delivery processes involve numerous interfaces and patient handoffs among multiple health care practitioners with varying levels of educational and occupational training. During the course of patients hospital stay, a patient may interact with different employees, including physicians, nurses, technicians, and others. Effective clinical practice thus involves many instances where critical information must be accurately communicated. When health care professionals are not communicating effectively, patient safety is at risk for several reasons: lack of critical information, misinterpretation of information, unclear orders over the telephone, and overlooked changes in status.
Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death. Medical errors, especially those caused by a failure to communicate, are a pervasive problem in todays health care organizations. According to the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, JCHAO), if medical errors appeared on the National Center for Health Statistics list of the top 10 causes of death in the United States, they would rank number 5ahead of accidents, diabetes, and Alzheimers disease, as well as AIDS, breast cancer, and gunshot wounds.
The 1999 Institute of Medicine report revealed that between 44,000 and 98,000 people die every year in U.S. hospitals because of medical errors. Even more disturbing, communication failures are the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 2004. More specifically, the Joint Commission cites communication failures as the leading root cause for medication errors, delays in treatment, and wrong-site surgeries, as well as the second most frequently cited root cause for operative and postoperative events and fatal falls. Traditional medical education emphasizes the importance of error-free practice, utilizing intense peer pressure to achieve perfection during both diagnosis and treatment. Errors are therefore perceived normatively as an expression of failure. This atmosphere creates an environment that precludes the fair, open discussion of mistakes required if organizational learning is to take place. In the early 1990s, Donald Berwick wrote about patients needing an open communication system instead of experiencing adverse events stemming from communication failures.
There is indeed an important role of communication and team collaboration in helping to reduce medical errors and increase patient safety.
What Are Communication and Team Collaboration? Websters Dictionary defines communication as the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs. It is important to consider that communication is not just verbal in form. One study states that 93 percent of communication is more affected by body language, attitude, and tone, leaving only 7 percent of the meaning and intent based on the actual words said. Whereas the spoken words contain the crucial content, their meaning can be influenced by the style of delivery, which includes the way speakers stand, speak, and look at a person. However, critical information is often transmitted via handwritten notes, e-mails, or text messages, which can lead to serious consequences if there is miscommunication.
Collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for patient care. Collaboration between physicians, nurses, and other health care professionals increases team members awareness of each others type of knowledge and skills, leading to continued improvement in decision making.
Effective teams are characterized by trust, respect, and collaboration. Teamwork is endemic to a system in which all employees are working for the good of a goal, who have a common aim, and who work together to achieve that aim.
When considering a teamwork model in health care, an interdisciplinary approach should be applied. Unlike a multidisciplinary approach, in which each team member is responsible only for the activities related to his or her own discipline and formulates separate goals for the patient, an interdisciplinary approach coalesces a joint effort on behalf of the patient with a common goal from all disciplines involved in the care plan. The pooling of specialized services leads to integrated interventions. The plan of care takes into account the multiple assessments and treatment regimens, and it packages these services to create an individualized care program that best addresses the needs of the patient. The patient finds that communication is easier with the cohesive team, rather than with numerous professionals who do not know what others are doing to manage the patient.
A study determined that improved teamwork and communication are described by health care workers as among the most important factors in improving clinical effectiveness and job satisfaction.
Another study shows that the priorities of patient care differed between members of the health care team, and that verbal communication between team members was inconsistent. Other evidence shows that more than one-fifth of patients hospitalized in the United States reported hospital system problems, including staff providing conflicting information and staff not knowing which physician is in charge of their care. Many of these unwanted effects can be traced back to poor communication and collaboration, and ineffective teamwork.
Unfortunately, many health care workers are used to poor communication and teamwork, as a result of a culture of low expectations that has developed in many health care settings.
This culture, in which health care workers have come to expect faulty and incomplete exchange of information, leads to errors because even conscientious professionals tend to ignore potential red flags and clinical discrepancies. They view these warning signals as indicators of routine repetitions of poor communication rather than unusual, worrisome indicators.
Although poor communication can lead to tragic consequences, a review of the literature also shows that effective communication can lead to the following positive outcomes: improved information flow, more effective interventions, improved safety, enhanced employee morale, increased patient and family satisfaction, and decreased lengths of stay. Fuss and colleagues and Gittell and others show that implementing systems to facilitate team communication can substantially improve quality of care.
Effective communication among staff encourages effective teamwork and promotes continuity and clarity within the patient care team. At its best, good communication encourages collaboration, fosters teamwork, and helps prevent errors.
Barriers to Effective Communication Health professionals tend to work autonomously, even though they may speak of being part of a team. Efforts to improve health care safety and quality are often jeopardized by the communication and collaboration barriers that exist between clinical staff. Although every organization is unique, the barriers to effective communication that organizations face have some common themes.
The barriers can occur within disciplines, most notably between physicians and residents, surgeons and anesthesiologists, and nurses and nurse managers. However, most often the barriers manifest between nurses and physicians. Even though doctors and nurses interact numerous times a day, they often have different perceptions of their roles and responsibilities as to patient needs, and thus different goals for patient care.
One barrier compounding this issue is that because the United States is one of the most ethnically and culturally diverse countries in the world, many clinicians come from a variety of cultural backgrounds. In all interactions, cultural differences can exacerbate communication problems. For example, in some cultures, individuals refrain from being assertive or challenging opinions openly. As a result, it is very difficult for nurses from such cultures to speak up if they see something wrong. In cultures such as these, nurses may communicate their concern in very indirect ways. Culture barriers can also hinder nonverbal communication. For example, some cultures ascribe specific meaning to eye contact, certain facial expressions, touch, tone of voice, and nods of the head.
Issues around gender differences in communication styles, values, and expectations are common in all workplace situations. In the health care industry, where most physicians are male and most nurses are female, communication problems are further accentuated by gender differences. A review of the organizational communication literature shows that a common barrier to effective communication and collaboration is hierarchies. Sutcliff and colleagues research concurs that communication failures in the medical setting arise from vertical hierarchical differences, concerns with upward influence, role conflict, and ambiguity and struggles with interpersonal power and conflict. Communication is likely to be distorted or withheld in situations where there are hierarchical differences between two communicators, particularly when one person is concerned about appearing incompetent, does not want to offend the other, or perceives that the other is not open to communication.
In health care environments characterized by a hierarchical culture, physicians are at the top of that hierarchy. Consequently, they may feel that the environment is collaborative and that communication is open while nurses and other direct care staff perceive communication problems. Hierarchy differences can come into play and diminish the collaborative interactions necessary to ensure that the proper treatments are delivered appropriately. When hierarchy differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can hinder communication and give the impression that the individual is unapproachable.
Staff who witness poor performance in their peers may be hesitant to speak up because of fear of retaliation or the impression that speaking up will not do any good. Relationships between the individuals providing patient care can have a powerful influence on how and even if important information is communicated.
Research has shown that delays in patient care and recurring problems from unresolved disputes are often the by-product of physician-nurse disagreement. Our research has identified a common trend in which nurses are either reluctant or refuse to call physicians, even in the face of a deteriorating status in patient care. Reasons for this include intimidation, fear of getting into a confrontational or antagonistic discussion, lack of confidentiality, fear of retaliation, and the fact that nothing ever seems to change. Many of these issues have to deal more with personality and communication style. The major concern about disruptive behaviors is how frequently they occur and the potential negative impact they can have on patient care. Our research has shown that 17 percent of respondents to our survey research in 2004-2006 knew of a specific adverse event that occurred as a result of disruptive behavior. A quote from one of the respondents illustrates this point: Poor communication post op because of disruptive reputation of physician resulted in delay treatment, aspiration, and eventual demise.
Leaders in both medicine and nursing have issued ongoing initiatives for the development of a cooperative rather than a competitive agenda to benefit patient care. A powerful incentive for greater teamwork among professionals is created by directing attention to the areas where changes are likely to result in measurable improvements for the patients they serve together, rather than concentrating on what, on the surface, seem to be irreconcilable professional differences. The fact that most health professionals have at least one characteristic in common, a personal desire to learn, and that they have at least one shared value, to meet the needs of their patients or clients, is a good place to start.
Establishing Culture to Support Communication and Team Collaboration Creating opportunities for different groups to just get together is a highly effective strategy enhancing collaboration and communication. These group interactions can be either formal or informal. Encouraging open dialogue, collaborative rounds, implementing pre-op and post-op team briefings, and creating interdisciplinary committees or task forces that discuss problem areas frequently provides an upfront solution that reduces the likelihood of disruptive events.
When a disruptive event does occur, some organizations have implemented a time-out, code white, or red light policy that addresses the issue in real time to prevent any further serious consequences.
Developing and implementing a standard set of behavior policies and procedures is vital. These policies need to be consistent and universally applied. There should not be a separate policy for any one particular discipline or service. For the medical staff, the policies should become part of the medical staff bylaws with signed agreements to abide by these policies at the time of appointment and re- credentialing. Included in the policies should be a standardized protocol outlining expected standards and the process for addressing disruptive behavior issues, recommendations, follow-up plans, and actions to be taken in the face of individual resistance or refusal to comply. Prior to implementation, make sure all employees are familiar with the existence, purpose, and intent of the policies and procedures. For the process to unfold, the organization needs to encourage its employees to report disruptive behaviors. The organization needs to address issues related to confidentiality, fear of retaliation, and the common feelings that there is a double standard and that nothing ever gets done. Reporting mechanisms should be made easy and must be supported by the presence of a non-punitive environment. The ideal vehicle for reporting is to address the situation in real time, but concerns about position, appropriateness, receptiveness, fear, hostility, and retaliation are significant impediments Appropriate vehicles for reporting may include reporting of the incident to a superior, filing an incident report, using a complaint or suggestion box, or reporting directly to a task force or interdisciplinary committee with assigned responsibilities for addressing these issues. Besides maintaining confidentiality and reducing risks of retaliation, one of the most crucial aspects of the reporting system is to give recognition and assurance that the complaints will be addressed and actions will be taken. Responses should be timely, appropriate, consistent, and provide necessary feedback and follow-up.
Taking action though appropriate intervention strategies is next. On one level, generic educational programs can do a lot to spread the message and teach basic skills necessary to promote effective communication. Appropriate topics should include sessions on team dynamics, communication skills, phone etiquette, assertiveness training, diversity training, conflict management, stress management, and any other courses necessary to foster more effective team functioning and communication flow. Courses should be offered to all staff and employees at the organization: physicians, physicians in training, nurses, nursing students, and all other staff who have patient contact or play a role in the delivery of patient care. For individuals who have consistently exhibited disruptive behavior, education may need to be supported by more focused sessions and specific counseling. Another important strategy is to promote and assure competency training at all levels of the health care team. This is a key factor affecting trust and respect, which have such a strong influence on team collaboration.
Focused team training programs have been of particular value. One of the newer approaches to improving team collaboration and patient safety is through the principles learned from the aviation industry. Fostering an environment of trust and respect, accountability, situational awareness, open communication, assertiveness, shared decision making, feedback, and education, interdisciplinary CRM training has brought significant improvements to communication flow in the peri-operative setting.
Having a clinical champion or early adopter who actively promotes the importance of appropriate behavior, communication, and team collaboration can be an extremely valuable asset. Champions can come from the executive ranks or through the voluntary interest and enthusiasm of other staff members. Co-champions may be even more effective. Some organizations have reported that having a nurse and physician (or other health care professional) go through a joint training program will help foster mutual cooperation and collaboration between the different disciplines. Follow-up and feedback bring closure to the process. It is important to let people know that their input is welcomed, follow-up actions will be taken, and appropriate feedback will be provided.
Effective clinical practice must not focus only on technological system issues, but also on the human factor. Good communication encourages collaboration and helps prevent errors. It is important for health care organizations to assess possible setups for poor communication and be diligent about offering programs and outlets to help foster team collaboration. By addressing this issue, health care organizations have an opportunity to greatly enhance their clinical outcomes.
CONCLUSION In healthcare, effective communication involves arriving at a shared understanding of a situation and in some instances a shared course of action. This requires a wide range of generic communication skills, from negotiation and listening, to goal setting and assertiveness, and being able to apply these generic skills in a variety of situations. Many factors have been reported as influencing effective communication in healthcare. These include individual abilities and characteristics, team behavior and systemic factors and the lack of organizational support of a culture of safety.
Effective clinical handover or endorsement, for example at shift changes, requires good communication. Ineffective handover or endorsement may lead to a failure to appreciate critical aspects of a patients condition or care, lead to delays in a patients treatment and result in adverse patient outcomes. Communicating complex information clearly and effectively is a challenge, but it is critical for ethical, high-quality health care. Many leaders of organizations throughout the health care system understand that cultural beliefs and values, linguistic diversity, literacy levels and other issues can affect the quality of health care communication. And poor quality communication can affect health outcomes and the long-term success of health care businesses. Taking a patient-centered approach to health care communication can help an organizations staff and leaders learn about the communication needs of the individuals and groups they serve.
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Allhoff, F., et.al. Improving Communication Improving Care. American Medical Association, 2006.
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Leonard, M., Graham, S., and Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care
ODaniel, M. & Rosenstein, A. Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Promoting Effective Communication Among Healthcare Professionals to Improve Patient Safety and Quality of Care, July 2010
http://www.health.vic.gov.au/quality council
Coiera, E. (2006). Communicating systems in healthcare
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